Provider Demographics
NPI:1053188425
Name:WILDE, DEANNA (LGSW, ADC-T)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:LGSW, ADC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3475
Mailing Address - Country:US
Mailing Address - Phone:320-231-9763
Mailing Address - Fax:320-235-0334
Practice Address - Street 1:328 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3475
Practice Address - Country:US
Practice Address - Phone:320-231-9763
Practice Address - Fax:320-235-0334
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31957104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1003042656Medicaid